Massage/Aromatherapy Massage

PEP Topic

Chronic Pain

Description

Aromatherapy is the use of fragrant oils, distilled from plants, to alter mood or improve health. Some studies have examined the effect of aromatherapy used with massage. Aromatherapy massage is massage therapy delivered by a therapist as aromatherapy oils are administered by inhalation. Massage with or without aromatherapy has been studied in patients with cancer for management of anxiety, caregiver strain and burden, constipation, chemotherapy-induced nausea and vomiting, depression, lymphedema, pain, sleep disturbance, and fatigue.

Research Evidence Summaries

Intervention Characteristics/Basic Study Process:

Massage therapists who were specially trained in massage therapy for patients with cancer discussed the massage intervention process with patients and asked them which parts of their body they would like to have massaged. Massage sessions lasted 10 to 15 minutes, using Swedish massage. The most common areas for massage chosen by patients were the feet and leg or back, neck, and shoulder areas. Once patients were enrolled in the study, oncology social workers met with patients to perform a baseline assessment of pretreatment outcomes. After the massage intervention, the oncology social worker met with the patient to assess posttreatment outcomes.

Sample Characteristics:

The study reported 251 patients with cancer (70% female, 30% male).

Mean patient age was 54.96 years.

Of the participants, 68.9% were Caucasian, 29.1% were Black, 1.2% were Asian, 0.4% were Hispanic, and 0.4% were Indian.

Multiple cancer types were included, but the most common type was gynecologic (25%).

Patients were recruited during a three-year period and were determined to be eligible for the study by their primary nurse.

Setting:

Patients were hospitalized at a major university hospital in southeastern Georgia.

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

The study used a nonrandomized, single-group, pre-/posttest, repeated-measures design.

Measurement Instruments/Methods:

A modified version of MacDonald’s Patient Evaluation of Massage Experience Scale was used.

Results:

The massage therapy intervention resulted in a statistically significant decline in fatigue mean scores (p < 0.001), which was observed between pre- and posttest treatment evaluations.

Limitations:

The study was not a randomized controlled trial; therefore, no neutral comparison group existed to test for baseline similarities or postintervention differences between groups.

A substantial number of patients refused to participate, particularly men. This may be a result of preconceived notions regarding massage and human touch. Changing massage nomenclature to “back rub” may be more broadly acceptable in future investigations.

The study was not a longitudinal design; therefore, it could not be determined how long the observed benefits lasted.

Study Purpose:

To compare the efficacy of massage therapy to a social attention condition in Taiwanese patients with cancer with bone metastases

Intervention Characteristics/Basic Study Process:

A five-day, two-group trial with a pre/post-test design was used.

The experimental intervention was 45 minutes of massage; condition control was caring therapist for a comparable amount of time.

Sample Characteristics:

The sample was 72 patients with cancer with bone metastasis.

Mean patient age was 50 years.

The sample was 42% male and 58% female.

The sample was Taiwanese, age 18 or older, oriented x3 (alert and normal), Chinese-speaking and reading, radiologically diagnosed with bone metastasis via bone scan, and reporting moderate bone pain of at least 4 on a 0–10 scale.

Patients were excluded if they were regularly receiving massage therapy, were undergoing surgeries or procedures during admission, or had allodynia, thrombocytopenia, spinal cord compression syndrome, deep vein thrombosis, or other contraindications to massage therapy.

Setting:

Single site

Inpatient setting

Five hospital oncology units

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

The study has clinical applicability for end-of-life and palliative care.

Study Design:

The study was a randomized, controlled clinical trial.

Measurement Instruments/Methods:

Present Pain Intensity (PPI) – Visual Analog Scale (VAS)

Mood VAS

Relaxation VAS

Sleep VAS

Symptom Distress Scale

Demographic and medical profiles

Results:

Pre- to postintervention effects: No statistical significance was shown in individual patients.

Results from MANCOVAs showed statistically significant intervention effects on pain, mood, and relaxation VASs, but not the sleep VAS.

There was a significant linear group by time effect on relaxation VAS in both groups: F (1, 69) = 10.39, p = 0.002, indicating a different pattern of change in relaxation VAS change scores between the groups.

Conclusions:

This trial documented therapeutic effects of massage on improving pain intensity, mood status, and muscle relaxation in patients with metastatic bone pain. The study has clinical implications supporting massage therapy and other medical modalities for optimal improvement in patients with cancer with bone metastases.

Limitations:

The study had a small sample, with less than 100 participants.

The patient population was heterogeneous.

The study involved a short course of therapy.

The study lacked multidimensional measurement of pain and patient binding.

Nursing Implications:

Massage therapy may play an important role in cancer bone pain, sleep, and, mood.

Study Purpose:

To test the hypothesis that massage would decrease pain and analgesic medicine use

To explore effects on quality of life and physical and emotional symptom distress

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to a massage treatment group or to a control group in which patients received simple touch controlled for time and attention. Individual baseline data for disease characteristics, pain, symptom distress, quality of life, functional status, expectations from massage, and concurrent interventions were collected within 72 hours of study inclusion and at three weekly visits over the three to four weeks of study participation, for measurement of sustained effects. Data collectors were blinded to study group assignment. Participants received up to three 30-minute treatments over two weeks with at least 24 hours between treatment sessions, according to a schedule jointly determined by the patient and the treatment provider. Treatment providers obtained immediate outcome data prior to and following each treatment. All participants received routine care in addition to study interventions. Massage intervention included gentle effleurage, petrissage, and myofascial trigger point release. The most frequently massaged areas were neck and upper back and arms, hands, lower legs, and feet. Massages were performed by licensed massage therapists who had at least six months’ experience working with patients with advanced cancer. Control touch included placement of both hands on the participant bilaterally on the neck, shoulder blades, lower back, calves, heels, clavicles, lower arms, hands, patellae, and feet with light and consistent pressure. All treatment providers had standardized hands-on training and were evaluated for competency.

Sample Characteristics:

The study reported on 348 patients.

Mean patient age was 65.2 years (SD = 14.4) in the experimental group, and 64.2 years (SD = 14.4) in the control group.

The sample was 61% female and 39% male.

The most common diagnoses were breast and lung cancers.

All patients had metastatic disease, 27% had bone metastasis, 54% had constant pain, and 26% had neuropathic pain.

Of the sample, 44% were married or in a committed relationship, 39%–42% had a college level or higher education, and 86% were non-Hispanic white.

In the experimental group, 77% were receiving care at home, and 81% were receiving care at home in the control group.

Mean worst pain in 24 hours in both groups was 6.4 or greater at baseline.

Setting:

Multisite

15 U.S. hospices and the University of Colorado Cancer Center

Study Design:

The study was a randomized, single-blind, controlled trial.

Measurement Instruments/Methods:

Memorial Pain Assessment Card (MPAC) using a 0–10 point scale for immediate effect

Brief Pain Inventory (BPI) for sustained measure

MPAC Mood Scale

McGill Quality of Life Questionnaire

Memorial Symptom Assessment Scale (MSAS)

Recording of name, dose, and frequency of medication for symptom management

Results:

Both massage and touch were associated with significant improvements in immediate and sustained pain outcomes. Massage was superior to touch, but the difference was not statistically significant. Both groups demonstrated statistical, but not clinically significant, improvement in BPI scores. Both massage and simple touch were reported to be associated with statistically significant immediate improvement in mood, with massage showing statistically superior effect compared to touch. Confidence intervals were provided, but significance levels were not reported. Both groups demonstrated improvement in physical and emotional symptom distress and quality of life across weekly evaluations, but there were no differences between groups. There were no adverse effects associated with the interventions, and no differences in general adverse events or mortality between groups. Differences in pain medication use were not reported.

Conclusions:

Both massage and simple touch appeared to have immediate beneficial effects on pain and mood in these patients. Both groups experienced slight improvement in pain, quality of life, and symptom distress over time. These changes were minimal, showing statistical significance but not clinical relevance.

Limitations:

Findings are limited to patients with very advanced cancer, the majority of whom were in hospice programs, and may not be applicable to other patient groups.

There was no usual care control group.

Having an appropriate attentional control group was useful, but given the findings that both study groups experienced benefits, the attention itself may be the most relevant factor in changes seen.

Nursing Implications:

Simple touch appeared to have a short-term positive effect on patient mood and pain experience. This is an intervention that should be easy to provide for patients and could be something that caregivers could also be educated to provide. This intervention could be useful for intermittent use as an adjunct to other interventions for pain management. Formal massage did not provide significantly greater effects. Given findings of simple touch in the population studied here, evaluation of this approach in other patient groups can be useful.

Study Purpose:

To determine if massage therapy and healing touch were effective in reducing anxiety, mood disturbance, pain, fatigue, and nausea and in improving the relaxation and satisfaction with care of patients receiving chemotherapy treatment

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to one of three groups: therapeutic massage, healing touch, or caring presence. All received four weekly 45-minute sessions of the intervention and four weeks of standard care (control). After four weeks, patients were crossed over to another intervention or the control. Order of the intervention and usual-care control were randomized. Pre- and post-assessments of pain, nausea, and vital signs were done at each session. Assessments of intervention effects were done at the beginning and end of each four-week session. Therapeutic massage was provided in a standardized fashion, using a Swedish massage protocol. Healing touch followed a previously developed protocol incorporating centering, unruffling, magnetic unruffling, full-body connection, mind clearing, chelation, and lymphatic drain. Presence consisted of patients lying down for 45 minutes with relaxing music and the presence of a therapist. The therapist asked patients how they were feeling and if they had any questions. Conversation may or may not have occurred, according to the patient’s preference; the purpose of the therapist was to be attentive but to avoid therapy or physical intervention. The control condition consisted of usual care, which the authors did not describe.

Sample Characteristics:

The study reported on a sample of 164 patients.

Mean patient age was 57.4 years, with a range of 27–83 years.

The sample was 87% female and 13% male.

The most common cancer types were breast, gynecologic or genitourinary, gastrointestinal, hematologic, and lung.

The majority of patients had stage III or IV disease, and 50% were in the first month of chemotherapy treatment.

All patients had a score of at least 3 on a 10-point scale of symptom severity. The most frequently reported symptoms were fatigue, pain, anxiety, and nausea.

Setting:

Single site

Outpatient setting

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

A randomized, controlled, parallel-group, crossover design was used.

Measurement Instruments/Methods:

Symptom rating scales (0–10)

Brief Pain Inventory

Brief Nausea Index

Profile of Mood States

Satisfaction measure according to a four-point Likert-type scale

Results:

Of those who initially entered the study, 29% dropped out. Half of the dropouts were due to changes in the cancer treatment protocol; half were because patients wanted an intervention different from the one assigned. Those who dropped out had higher pain, nausea, mood disturbance, and fatigue at baseline (p < 0.05) than those who did not.

Massage and healing touch groups showed immediate post-session reduction of respiratory rate, heart rate, and blood pressure (p < 0.01), and these interventions were more effective (p < 0.01) in achieving these reductions than were control and presence conditions. Massage and healing touch were associated with pre- and post-session reduction in current pain (p < 0.001).

Over the four-week study period, mood disturbance decreased over time in all patients. Massage therapy, compared to the control condition, was more effective at reducing total mood disturbance (p = 0.004) and anxiety (p = 0.023). Healing touch reduced mood disturbance (p = 0.003) and fatigue (p = 0.028).

Mean pain scores in all cases declined over time.

There were no differences between groups in nausea or use of antiemetics.

There were no differences between groups in overall satisfaction. Massage and healing touch were associated with higher satisfaction with the intervention than was presence (p < 0.0001).

Limitations:

The control condition may not have provided appropriate attentional control.

The study had risk of bias due to no blinding.

The anxiety measure was not a rigorous, valid tool; it was a 10-point scale.

The study had a large drop-out rate.

Nursing Implications:

Massage therapy and therapeutic touch can be beneficial to patients because the interventions induce physical relaxation and reduce pain, fatigue, and anxiety. In this study, these interventions were more effective in this regard than was therapeutic presence alone. Massage therapy and therapeutic touch are complementary therapies that nurses can consider and advocate for on behalf of patients who may benefit from them.

Study Purpose:

To determine the feasibility and effects of providing therapeutic massage at home for patients with metastatic cancer

Intervention Characteristics/Basic Study Process:

Massage therapy was the experimental intervention. Professional massage therapists provided the intervention in patients’ homes up to three times during the first week after enrollment. The duration of massage ranged from 15–45 minutes; the duration and amount of pressure was modified based on patients’ comfort. Control groups received either a no-touch intervention or usual care. The no-touch intervention consisted of massage therapists being with patients and holding hands without any healing intervention in their homes. Usual care did not include a home visit. Data were collected at baseline and four times after the intervention during a weekly assessment.

Phase of Care and Clinical Applications:

Study Design:

Pilot randomized, controlled trial

No blinding

Measurement Instruments/Methods:

State-Trait Anxiety Inventory (STAI)

Brief Pain Inventory-Short Form

Global measure of perceived stress

Results:

Massage therapy at home was a feasible intervention. The mean number of massage therapy sessions per patient was 2.8. There were no serious adverse events related to the interventions. There were no significant changes in the primary outcomes (i.e., pain, anxiety, and alertness). There were only trends toward improvement in pain and sleep of patients after therapeutic massage but not in patients in the control groups. Researchers identified a significant improvement in the quality of life of patients who received massage therapy after one-week follow-up, but the difference was not sustained at one month.

Conclusions:

The study shows that therapeutic massage at home is a feasible intervention. However, its effects on anxiety or pain were not conclusive. The small and uneven sample sizes across groups are a major weakness of the study. Although two measures were used for anxiety, the authors did not state which measures were used for the main analysis. Validity of measurements (i.e., alertness, and quality-of-life measure) is also problematic.

Limitations:

Small sample (< 30)

Risk of bias (no control group)

Measurement of validity/reliability questionable

Nursing Implications:

The role of nurses for this intervention is not clear. The massage therapy given in the present study was a professional intervention.

Year of publication, as defined by the search strategy, varied by database. The most recent date was September 2006.

Search keywords were massage, aromatherapy, therapeutic touch, essential oil, volatile oil and cancer or neoplasm or oncolog* or palliate* or terminal or hospice.

Studies were included in the review if they

Were randomized controlled trials (RCTs)

Involved adult patients with cancer who were receiving care in any healthcare setting

Included any type of massage, with a systemic goal, provided by a therapist with a recognized qualification

Produced patient-reported outcomes, reported by means of reliable and valid assessment tools, of physical or psychological symptoms and quality of life

Included the means by which the reliability and validity of assessment tools were evaluated.

Studies were excluded if the purpose of the massage was a specific localized physical effect without a specific systemic aim. For example, a study involving prostatic massage to obtain a semen sample was excluded.

Literature Evaluated:

After elimination of duplicates from the initial search, investigators considered 1,321 references. Of these, investigators chose 10 studies for analysis, using the Jadad scoring approach and CONSORT Statement to appraise study quality. Investigators also used sample size and duration of follow-up to evaluate studies. Given the range of massage techniques and patients, meta-analysis was impossible. Three investigators reviewed studies independently.

Sample Characteristics:

The review reported on 386 patients from nine studies.

One of the initial references was a duplicate report of a single study.

One study was based on personal communication, rather than a final published report.

Results:

Patients were assessed 4–16 times, with all patients assessed before and after the intervention or control period.

Follow-up was limited. One study assessed patients three weeks after the last massage.

Five trials assessed psychological outcomes, including outcomes related to anxiety and depression.

Seven trials assessed physical symptoms and quality of life.

One study found a significant post-massage decrease in pain for males only. One study found a significant reduction in pain after massage but not after the control period. One study showed pain reduction after the first and third massage, but not after the second and fourth, and a nonsignificant trend of greater pain improvement in the massage group than in the group that did not receive massage.

One study showed significant reduction of depression with massage, and one study showed no change.

Most studies reported decreases in anxiety and other psychological benefits; however, results relating to depression were equivocal across studies.

Adverse effects included a single case of skin rash in one trial and, in another trial that involved the use of essential oils, a higher incidence of digestive problems.

Conclusions:

The authors stated that results were inconclusive; however, reported results showed that massage had a preponderantly positive effect in regard to anxiety reduction.

Limitations:

This review did not discuss the patients' treatment phase, so effects relating to specific groups of patients were unspecified.

Authors did not know how and if variations in massage style affected outcomes.

Trials that included the use of oils used different oils, so the authors could draw no conclusions regarding the effect of aromatherapy.

No evidence was available to assess long-term effects of massage. Authors found that research of long-term effects, as reported in the studies, was of low quality.

Although inclusion criteria demanded that all studies be RCTs, results suggest that one study did not include a separate control group.

Nursing Implications:

Two studies included in the review used a crossover design, and one of these showed significant results after massage but not after the control period. This suggests that crossover design may be particularly applicable to this area of research and that the effects of massage are immediate and time sensitive.